Functional endoscopic sinus surgery

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Functional endoscopic sinus surgery
CHOANAL POLYP PerfectlyClear.jpg
Large nasal polyp (round mass, center), which is commonly treated and removed by FESS
ICD-9-CM 22.11

Functional endoscopic sinus surgery (FESS) is a procedure that is used to treat sinusitis and other conditions that affect the sinuses. Sinusitis is an inflammation of the sinuses that can cause symptoms such as congestion, headaches, and difficulty breathing through the nose.

Contents

FESS is a minimally invasive procedure that is performed using an endoscope, a thin, rigid tube with a camera on the end. The endoscope is inserted through the nostrils, allowing the surgeon to visualize the inside of the nasal passages and sinuses. The surgeon can then remove any tissue or obstruction that is blocking the sinuses, such as swollen or infected tissue.

FESS is generally considered to be a safe and effective treatment for sinusitis and other conditions that affect the sinuses. It can help to alleviate symptoms and improve the overall functioning of the sinuses. However, as with any medical procedure, there are potential risks and complications that should be discussed with a healthcare provider.

History

The first recorded instance of endoscopy being used to visualize the nasal passage took place in Berlin in 1901. [1] Alfred Hirschmann, a designer and maker of medical instruments, modified a cystoscope for use in the nasal cavity. In October 1903, Hirschmann published "Endoscopy of the nose and its accessory sinuses." [2] In 1910, M. Reichart performed the first endoscopic sinus surgery using a 7 mm endoscope.

In 1925, Maxwell Maltz created the term "sinuscopy," referring to the endoscopic method of visualizing the sinuses. Maltz also encouraged the use of endoscopes as a diagnostic tool for nasal and sinus abnormalities. [1]

Heinz Stammberger at the end of course at Tarabichi Stammberger Ear and Sinus Institute two months before he died. Heinz Stammberger.jpg
Heinz Stammberger at the end of course at Tarabichi Stammberger Ear and Sinus Institute two months before he died.
Professor Stammberger teaching at the Tarabichi Stammberger Ear and Sinus Institute TSESI.jpg
Professor Stammberger teaching at the Tarabichi Stammberger Ear and Sinus Institute

In the 1960s, Harold Hopkins, then a PhD at the University of Reading, used his background in physics to develop an endoscope that provided more light and had drastically better resolution than previous endoscopes. Hopkins' rod optic system is widely credited with being a turning point for nasal endoscopy. [1] Utilizing Hopkins' rod optic system, Walter Messenklinger visualized, recorded, and mapped the anatomy of the paranasal sinuses and the lateral nasal walls - specifically, the mucociliary routes - in cadavers. [3] In 1978, Messerklinger published the book titled "Endoscopy of the Nose" on his findings, and his proposed methods to utilize nasal endoscopy for diagnosis. [4]

Heinz Stammberger, [5] a head and neck surgeon who worked at the University of Graz with Messerklinger was captivated by the technique and the implications for pathophysiology and treatment of sinus disease. He adopted the technique and became identified with it. He traveled the world advocating and popularizing the technique and he carried out multiple courses both at University of Graz and around the world. He later met David Kennedy, a physician at Johns Hopkins University, and together, they worked with the surgical instrument maker Karl Storz to develop instruments for use in endoscopic sinus surgery, and coined the term Functional Endoscopic Sinus Surgery. [3] Stammberger and Kennedy published multiple papers on FESS use and technique, and in 1985 the first North American course on FESS was taught at Johns Hopkins Hospital in Baltimore. [1] Stammberger, the chair of otolaryngology at University of Graz, and Kennedy, refined the techniques and provided hands-on courses on the techniques throughout the world. Stammberger retired from his position as the chair of the department in Graz and moved to Dubai, where he worked with Muaaz Tarabichi, also known as "the father of endoscopic ear surgery", to establish the Tarabichi Stammberger Ear and Sinus Institute (TSESI), a center dedicated to the advancement of endoscopic ear and sinus surgery. [6] Stammberger died in 2018. [5] There was a rise in the overall number of endoscopic sinus surgery procedures performed between 2010 - 2019 in the UK which coincided with a reduction in the number of open procedures performed over the same period. [7]

Medical applications

Functional endoscopic sinus surgery is most commonly used to treat chronic rhinosinusitis (CRS), [8] only after all non-surgical treatment options such as antibiotics, topical nasal corticosteroids, and nasal lavage with saline solutions [9] have been exhausted. CRS is an inflammatory condition in which the nose and at least one sinus become swollen and interfere with mucus drainage. [9] It can be caused by anatomical factors such as a deviated septum or nasal polyps (growths), as well as infection. Symptoms include difficulty breathing through the nose, swelling and pain around the nose and eyes, postnasal drainage down the throat, and difficulty sleeping. [10] CRS is a common condition in children and young adults. [11]

The purpose of FESS in treatment of CRS is to remove any anatomical obstructions that prevent proper mucosal drainage. A standard FESS includes removal of the uncinate process, and opening of the ethmoid air cells and Haller cells [12] as well as the maxillary ostium, if necessary. If any nasal polyps obstructing ventilation or drainage are present, they are also removed. [8] In the case of paranasal sinus/nasal cavity tumors (benign or cancerous), an otolaryngologist can perform FESS to remove the growths, sometimes with the help of a neurosurgeon, depending on the extent of the tumor. In some cases, a graft of bone or skin is placed by FESS to repair damages by the tumor. [13]

In the thyroid disorder known as Graves' ophthalmopathy, inflammation and fat accumulation in the orbitonasal region cause severe proptosis. [14] In cases that have not responded to corticosteroid treatment, FESS can be used to decompress the orbital region by removing the ethmoid air cells and lamina papyracea. Bones of the orbital cavity or portions of the orbital floor may also be removed. [1] [ citation needed ]

The endoscopic approach to FESS is a less invasive method than open sinus surgery, which allows patients to be more comfortable during and after the procedure. Entering the surgical field via the nose, rather than through an incision in the mouth as in the previous Caldwell-Luc method, decreases risk of damaging nerves which innervate the teeth. [8] Because of its less-invasive nature, FESS is a common option for children with CRS or other sinonasal complications.

It has been suggested that one of the main objectives in FESS surgery is to allow for the introduction of local therapeutic agents (such as steroids) to the sinuses. Research has shown that a special modification of the nozzle of the nasal spray in patients who had FESS allows for better delivery of local therapeutic agents into the ethmoid sinuses. [15]

Outcomes and complications

Functional Endoscopic Sinus Surgery is considered a success if most of the symptoms, including nasal obstruction, sleep quality, olfaction and facial pain, are resolved after a 1-2 month postoperative healing period. [8] [16] [17] Reviews of FESS as a method for treating chronic rhinosinusitis have shown that a majority of patients report increased quality of life after undergoing surgery. [18] [16] The success rate of FESS in treating adults with CRS has been reported as 80-90%, [19] and the success rate in treating children with CRS has been reported as 86-97%. [11]

The most common complication of FESS is cerebrospinal fluid leak (CSFL), which has been observed in about 0.2% of patients. Generally, CSFL arises during surgery and can be repaired with no additional related complications postoperatively. Other risks of surgery include infection, bleeding, double vision usually lasting a few hours, numbness of the front teeth, orbital hematoma, decreased sense of smell, and blindness. [20] [21] The medial rectus muscle may be damaged. [22] Blindness is the single most serious complication of FESS, and results from damage to the optic nerve during surgery. Serious complications such as blindness occur in only 0.44% of cases, as determined by a study performed in the United Kingdom. [8]

A Cochrane review in 2006 based on three randomized control trials concluded that FESS has not been shown to provide significantly better results than medical treatment for chronic rhinosinusitis. [23] Another Cochrane review looked at postoperative care of patients after FESS using debridement (removal of blood clots, crusts, and secretions from the nasal and sinus cavities under local anaesthetic), but the evidence from the available clinical trials was uncertain. The debridement procedure after FESS may make little or no difference to health‐related quality of life or disease severity. There may be a lower risk of adhesions but whether this has any impact on long‐term outcomes is unknown. [24]

Functional sinus surgery had been grossly overutilized as a way of treating headache based on an assumption of a sinus etiology of the different types of primary headache. Many patients, primary care providers, and even specialists confuse any frontal migraine for sinus disease. Multiple attempts at further definition of primary headache and or sinus headache has been suggested by the International Headache Society and the American Academy of Otolaryngology-Head and Neck Surgery. [25] It has been suggested early on that such a confusion might be a cause of failure of functional endoscopic sinus surgery. [26]

Related Research Articles

<span class="mw-page-title-main">Otorhinolaryngology</span> Medical specialty

Otorhinolaryngology is a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck. Doctors who specialize in this area are called otorhinolaryngologists, otolaryngologists, head and neck surgeons, or ENT surgeons or physicians. Patients seek treatment from an otorhinolaryngologist for diseases of the ear, nose, throat, base of the skull, head, and neck. These commonly include functional diseases that affect the senses and activities of eating, drinking, speaking, breathing, swallowing, and hearing. In addition, ENT surgery encompasses the surgical management of cancers and benign tumors and reconstruction of the head and neck as well as plastic surgery of the face, scalp, and neck.

<span class="mw-page-title-main">Sinusitis</span> An inflammation of the mucous membrane that lines the sinuses resulting in symptoms

Sinusitis, also known as rhinosinusitis, is an inflammation of the mucous membranes that line the sinuses resulting in symptoms that may include thick nasal mucus, a plugged nose, and facial pain.

<span class="mw-page-title-main">Nasal polyp</span> Noncancerous growths within the nose or sinuses

Nasal polyps (NP) are noncancerous growths within the nose or sinuses. Symptoms include trouble breathing through the nose, loss of smell, decreased taste, post nasal drip, and a runny nose. The growths are sac-like, movable, and nontender, though face pain may occasionally occur. They typically occur in both nostrils in those who are affected. Complications may include sinusitis and broadening of the nose.

<span class="mw-page-title-main">Nasal irrigation</span> Personal hygiene practice for rinsing out nasal passages

Nasal irrigation is a personal hygiene practice in which the nasal cavity is washed to flush out mucus and debris from the nose and sinuses, in order to enhance nasal breathing. Nasal irrigation can also refer to the use of saline nasal spray or nebulizers to moisten the mucous membranes.

<span class="mw-page-title-main">Post-nasal drip</span> Medical condition

Post-nasal drip (PND), also known as upper airway cough syndrome (UACS), occurs when excessive mucus is produced by the nasal mucosa. The excess mucus accumulates in the back of the nose, and eventually in the throat once it drips down the back of the throat. It can be caused by rhinitis, sinusitis, gastroesophageal reflux disease (GERD), or by a disorder of swallowing. Other causes can be allergy, cold, flu, and side effects from medications.

Balloon sinuplasty is a procedure that ear, nose and throat surgeons may use for the treatment of blocked sinuses. Patients diagnosed with sinusitis but not responding to medications may be candidates for sinus surgery. Balloon technology was initially cleared by the U.S. Food and Drug Administration in 2005 and is an endoscopic, catheter-based system for chronic sinusitis. It uses a balloon over a wire catheter to dilate sinus passageways. The balloon is inflated with the goal of dilating the sinus openings, widening the walls of the sinus passageway and restoring normal drainage.

Chronic atrophic rhinitis, or simply atrophic rhinitis, is a chronic inflammation of the nose characterised by atrophy of nasal mucosa, including the glands, turbinate bones and the nerve elements supplying the nose. Chronic atrophic rhinitis may be primary and secondary. Special forms of chronic atrophic rhinitis are rhinitis sicca anterior and ozaena. It can also be described as the empty nose syndrome.

Rhinosinusitis is a simultaneous infection of the nasal mucosa (rhinitis) and an infection of the mucosa of the paranasal sinuses (sinusitis). A distinction is made between acute rhinosinusitis and chronic rhinosinusitis.

<span class="mw-page-title-main">Inverted papilloma</span> Medical condition

An inverted papilloma, also known as Ringertz tumour, is a type of tumor in which surface epithelial cells grow downward into the underlying supportive tissue. It may occur in the nose and/or sinuses or in the urinary tract. When it occurs in the nose or sinuses, it may cause symptoms similar to those caused by sinusitis, such as nasal congestion. When it occurs in the urinary tract, it may cause blood in the urine.

Endoscopic ear surgery (EES) is a minimally invasive alternative to traditional ear surgery and is defined as the use of the rigid endoscope, as opposed to a surgical microscope, to visualize the middle and inner ear during otologic surgery. During endoscopic ear surgery the surgeon holds the endoscope in one hand while working in the ear with the other. To allow this kind of single-handed surgery, different surgical instruments have to be used. Endoscopic visualization has improved due to high-definition video imaging and wide-field endoscopy, and being less invasive, EES is gaining importance as an adjunct to microscopic ear surgery.

Antral lavage is a largely obsolete surgical procedure in which a cannula is inserted into the maxillary sinus via the inferior meatus to allow irrigation and drainage of the sinus. It is also called proof puncture, as the presence of an infection can be proven during the procedure. Upon presence of infection, it can be considered as therapeutic puncture. Often, multiple repeated lavages are subsequently required to allow for full washout of infection.

Caldwell-Luc surgery, Caldwell-Luc operation, also known as Caldwell-Luc antrostomy, and Radical antrostomy, is an operation to remove irreversibly damaged mucosa of the maxillary sinus. It is done when maxillary sinusitis is not cured by medication or other non-invasive technique. The approach is mainly from the anterior wall of the maxilla bone. It was introduced by George Caldwell (1893)and Henry Luc (1897). The maxillary sinus is entered from two separate openings, one in the canine fossa to gain access to the antrum and other in the naso antral wall for drainage.

<span class="mw-page-title-main">Fungal sinusitis</span> Inflammation of the paranasal sinuses due to fungal infection

Fungal sinusitis or fungal rhinosinusitis is the inflammation of the lining mucosa of the paranasal sinuses due to a fungal infection. It occurs in people with reduced immunity. The maxillary sinus is the most commonly involved. Fungi responsible for fungal sinusitis are Aspergillus fumigatus (90%), Aspergillus flavus, and Aspergillus niger. Fungal sinusitis occurs most commonly in middle-aged populations. Diabetes mellitus is the most common risk factor involved.

Eustachian tube dysfunction (ETD) is a disorder where pressure abnormalities in the middle ear result in symptoms.

Muaaz Tarabichi is a Syrian otolaryngologist, lecturer, researcher, and author. He is recognized around the world as the father of endoscopic ear surgery. He is the co-founder of Tarabichi Stammberger Ear and Sinus Institute. He was elected as the chairman of the International Advisory Board of the American Academy of Otolaryngology–Head and Neck Surgery.

<span class="mw-page-title-main">Heinz Stammberger</span> German-Austrian surgeon (1946–2018)

Heinz Stammberger (1946-2018) was a German-Austrian teacher, and researcher in the field of sinus surgery and otolaryngology. He was an Emeritus Professor and Head of the Department of General ORL, H&NS of the Medical University of Graz.

Nasal surgery is a medical procedure designed to treat various conditions that cause nasal blockages in the upper respiratory tract, for example nasal polyps, inferior turbinate hypertrophy, and chronic rhinosinusitis. It encompasses several types of techniques, including rhinoplasty, septoplasty, sinus surgery, and turbinoplasty, each with its respective postoperative treatments. Furthermore, nasal surgery is also conducted for cosmetic purposes. While there are potential risks and complications associated, the advancement of medical instruments and enhanced surgical skills have helped mitigate them.

<span class="mw-page-title-main">Odontogenic sinusitis</span> Infectious disease

Odontogenic sinusitis is a type of sinusitis, specifically caused by dental infections or procedures. Comprising approximately 10-12% of all chronic sinusitis cases, this condition primarily affects the maxillary sinus, which is in close proximity to the upper teeth.

<span class="mw-page-title-main">Valerie Lund</span> British rhinologist

Dame Valerie Joan Lund is a British surgeon and emeritus Professor in Rhinology at University College London. Lund has worked on endoscopic endonasal surgery and studies sinonasal conditions She was elevated from CBE to DBE in the 2024 New Year Honours.

David William Kennedy is an American academician, surgeon, and otolaryngologist. He is currently serving as an emeritus professor at the University of Pennsylvania.

References

  1. 1 2 3 4 5 Tajudeen BA, Kennedy DW (June 2017). "Thirty years of endoscopic sinus surgery: What have we learned?". World Journal of Otorhinolaryngology - Head and Neck Surgery. 3 (2): 115–121. doi:10.1016/j.wjorl.2016.12.001. PMC   5683659 . PMID   29204590.
  2. ↑ Hirschmann A (October 1903). "Endoscopy of the nose and its accessory sinuses". The Laryngoscope. 13 (10): 810. doi: 10.1288/00005537-190310000-00015 .
  3. 1 2 Kane KJ (17 January 2018). "The early history and development of endoscopic sinonasal surgery in Australia: 1985–2005". Australian Journal of Otolaryngology. 1 (1): 7. doi: 10.21037/ajo.2018.01.08 .
  4. ↑ Walter M (1978). Endoscopy of the nose. Baltimore: Urban & Schwarzenberg. ISBN   0806712112. OCLC   3447558.
  5. 1 2 "Professor Heinz Stammberger (1946-2018): The Father of Endoscopic Sinus Surgery". ENT & Audiology News. Retrieved 8 February 2021.
  6. ↑ "Shifting paradigms – how a visionary can change a specialty". ENT & Audiology News. Retrieved 8 February 2021.
  7. ↑ Gupta KK, Jolly K, Bhamra N, Osborne MS, Ahmed SK (July 2021). "The evolution of sinus surgery in England in the last decade - An observational study". World Journal of Otorhinolaryngology - Head and Neck Surgery. 7 (3): 240–246. doi:10.1016/j.wjorl.2020.10.002. ISSN   2589-1081. PMC   8356113 . PMID   34430832.
  8. 1 2 3 4 5 Slack R, Bates G (September 1998). "Functional endoscopic sinus surgery". American Family Physician. 58 (3): 707–18. PMID   9750539.
  9. 1 2 Cazzavillan A, Castelnuovo P, Berlucchi M, Baiardini I, Franzetti A, Nicolai P, et al. (August 2012). "Management of chronic rhinosinusitis". Pediatric Allergy and Immunology. 23 (Suppl 22): 32–44. doi:10.1111/j.1399-3038.2012.01322.x. PMID   22762852. S2CID   8635561.
  10. ↑ "Chronic sinusitis - Symptoms and causes". Mayo Clinic. Retrieved 9 June 2018.
  11. 1 2 Makary CA, Ramadan HH (June 2013). "The role of sinus surgery in children". The Laryngoscope. 123 (6): 1348–52. doi:10.1002/lary.23961. PMID   23361382. S2CID   7977026.
  12. ↑ Levine CG, Casiano RR (February 2017). "Revision Functional Endoscopic Sinus Surgery". Otolaryngologic Clinics of North America. 50 (1): 143–164. doi:10.1016/j.otc.2016.08.012. PMID   27888911.
  13. ↑ "Treatment of Sinus Tumors". care.american-rhinologic.org. Archived from the original on 27 December 2018. Retrieved 9 June 2018.
  14. ↑ Cury SS, Oliveira M, Síbio MT, Clara S, Luvizotto RA, Conde S, et al. (May 2018). "Graves' ophthalmopathy: low-dose dexamethasone reduces retinoic acid receptor-alpha gene expression in orbital fibroblasts". Archives of Endocrinology and Metabolism. 62 (AHEAD): 366–369. doi: 10.20945/2359-3997000000044 . PMC   10118777 . PMID   29791662.
  15. ↑ Kapadia M, Grullo PE, Tarabichi M (August 2019). "Comparison of short nozzle and long nozzle spray in sinonasal drug delivery: a cadaveric study". Ear, Nose & Throat Journal. 98 (7): E97–E103. doi: 10.1177/0145561319846830 . ISSN   0145-5613. PMID   31064245.
  16. 1 2 Prasad S, Fong E, Ooi EH (July 2017). "Systematic review of patient-reported outcomes after revision endoscopic sinus surgery". American Journal of Rhinology & Allergy. 31 (4): 248–255. doi:10.2500/ajra.2017.31.4446. PMID   28716176. S2CID   4972917.
  17. ↑ Sukato DC, Abramowitz JM, Boruk M, Goldstein NA, Rosenfeld RM (February 2018). "Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis". Otolaryngology–Head and Neck Surgery. 158 (2): 249–256. doi:10.1177/0194599817737977. PMID   29065273. S2CID   23002331.
  18. ↑ Soler ZM, Jones R, Le P, Rudmik L, Mattos JL, Nguyen SA, et al. (March 2018). "Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis". The Laryngoscope. 128 (3): 581–592. doi:10.1002/lary.27008. PMC   5814358 . PMID   29164622.
  19. ↑ Stammberger H, Posawetz W (1990). "Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique". European Archives of Oto-Rhino-Laryngology. 247 (2): 63–76. doi:10.1007/bf00183169. PMID   2180446. S2CID   33308615.
  20. ↑ "Functional Endoscopic Sinus Surgery". UNC Otolaryngology/Head and Neck Surgery. Archived from the original on 12 November 2020. Retrieved 9 June 2018.
  21. ↑ "Functional Endoscopic Sinus Surgery - Otorhinolaryngology - Head & Neck Surgery". Otorhinolaryngology - Head & Neck Surgery. McGovern Medical School. 7 September 2012. Retrieved 11 June 2018.
  22. ↑ Huang CM, Meyer DR, Patrinely JR, Soparkar CN, Dailey RA, Maus M, et al. (January 2003). "Medial Rectus Muscle Injuries Associated With Functional Endoscopic Sinus Surgery: Characterization and Management". Ophthalmic Plastic & Reconstructive Surgery. 19 (1): 25–37. doi:10.1097/00002341-200301000-00004. ISSN   0740-9303. PMID   12544790. S2CID   43492945.
  23. ↑ Khalil HS, Nunez DA (July 2006). "Functional endoscopic sinus surgery for chronic rhinosinusitis". The Cochrane Database of Systematic Reviews (3): CD004458. doi:10.1002/14651858.cd004458.pub2. PMID   16856048. S2CID   27570565.
  24. ↑ Tzelnick S, Alkan U, Leshno M, Hwang P, Soudry E, et al. (Cochrane ENT Group) (November 2018). "Sinonasal debridement versus no debridement for the postoperative care of patients undergoing endoscopic sinus surgery". The Cochrane Database of Systematic Reviews. 2018 (11): CD011988. doi:10.1002/14651858.CD011988.pub2. PMC   6517168 . PMID   30407624.
  25. ↑ Levine H, Setzen M, Cady R, Dodick D, Schreiber C, Eross E, et al. (March 2006). "An Otolaryngology, Neurology, Allergy, and Primary Care Consensus on Diagnosis and Treatment of Sinus Headache". Otolaryngology–Head and Neck Surgery. 134 (3): 516–523. doi:10.1016/j.otohns.2005.11.024. PMID   16500456. S2CID   30982315.
  26. ↑ Tarabichi M (June 2000). "Characteristics of sinus-related pain☆". Otolaryngology–Head and Neck Surgery. 122 (6): 842–847. doi:10.1016/S0194-5998(00)70011-8. PMID   10828796.
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